Median Tegner Activity Score Research Articles

Long-term clinical and radiological outcome of a cementless titanium-coated total knee arthroplasty system.

To ensure a high-quality standard, it is important to frequently evaluate different prostheses models to avoid prostheses with high failure rates. Thus, the aim of the study was to evaluate the long-term outcome of the uncemented titanium-coated total knee arthroplasty (TKA) system (Advanced Coated System (ACS) III, Implantcast, GERMANY). We hypothesized that the ACS III would have a similar performance as other cemented TKA systems. A total of 540 ACS III mobile-bearing knee joint prostheses were implanted in 495 patients. The visual analogue scale (VAS) score, Tegner activity score (TAS), knee society score (KSS), Western Ontario and McMaster (WOMAC) score, and the Short Form 12 (SF-12) score for the evaluation of quality of life (QoL) were taken after at least 9years of follow-up. In addition, we measured range of motion (ROM) and assessed potential sex differences. In addition, the survival analysis was calculated at a median follow-up of 16.7years. At the final follow-up, 142 patients had died, and 38 had been lost to follow-up. The rate of revision-free implant survival at 16.7years was 90.0% (95% CI 87.1-92.2%) and the rate of infection-free survival was 97.0% (IQR 95.2-98.2%). The reasons for revision surgery were aseptic loosening (32.9%), followed by infection (27.1%), inlay exchange (15.9%), and periprosthetic fractures (5.7%). At the clinical follow-up visit, the mean VAS score was 1.9 ± 1.9, the median TAS was 3 (IQR 2-4), and the mean KSS for pain and function were 83.5 ± 15.3 and 67.5 ± 25.2, respectively. The mean WOMAC score was 81.1 ± 14.9, and the median SF-12 scores for physical and mental health were 36.9 (IQR 29.8-45.1) and 55.8 (IQR 46.2-61.0), respectively. The mean knee flexion was 102.0° ± 15.4°. Male patients had better clinical outcome scores than female patients [SF-12 mental health score, p = 0.037; SF-12 physical health score, p = 0.032; KSS pain score (p < 0.001), and KSS functional score (p < 0.001)]. The ACS III TKA system is a suitable option for the treatment of end-stage osteoarthritis of the knee joint because of its adequate long-term survival. Our findings are in line with published data on similar TKA systems that have shown favourable clinical scores in males. Level III-Retrospective cohort study.

Fixed lateral unicompartmental knee replacement is a reliable treatment for lateral compartment osteoarthritis after mobile-bearing medial unicompartmental replacement

PurposeLateral osteoarthritis following medial unicompartmental knee replacement (UKR) is usually treated with total knee replacement, however, lateral UKR is a less invasive option that preserves a well-functioning medial UKR. This study aimed to determine the 5-year outcome of the cemented Fixed Lateral Oxford UKR (FLO) when used for the treatment of severe lateral disease after medial Oxford unicompartmental knee replacement.MethodsForty-four knees with lateral bone-on-bone osteoarthritis (n = 43) and avascular necrosis (n = 1) treated with the FLO following medial Oxford UKR were followed up prospectively. The Oxford Knee Score (OKS) and Tegner Activity Score (TAS) were collected pre- and post-operatively. Life-table analysis was used to determine survival rates.ResultsThe mean patient age at the time of FLO surgery was 74.4 years with a mean time of 12.1 years between the primary medial UKR and the conversion to a bi-UKR with a FLO. Mean follow-up of the FLO was 3.5 years. After FLO no intra-operative or medical complications, re-admissions, or mortality occurred. There was one reoperation in which a bearing was exchanged for a medial bearing dislocation. There were no revisions of the FLO, so the FLO survival rate at 5 years was 100% (24 at risk). The mean pre-operative OKS was 22, which significantly (p < 0.0001) improved to a mean of 42, 42, and 40 at 1, 2, and 5 years, respectively. The median TAS had a non-significant improvement from 2.5 (Range 0–8) pre-operatively to 2 (Range 1–6) at 5 years postoperatively.ConclusionThe FLO is a reliable treatment for lateral osteoarthritis following medial UKR. At 5 years there was a 100% survival of the FLO with a mean OKS of 40.Level of evidenceIV, Prospective Case Series.

Clinical outcome and healing rate after meniscal bucket handle tear repair

BackgroundReports combining patient-reported outcome measures, clinical evaluation, and radiographic assessment of postoperative healing after arthroscopic repair of bucket-handle meniscal tears (BHMT) are scarce.MethodsPatients who underwent arthroscopic repair for acute traumatic BHMTs between October 2011 and March 2016 with a minimum follow-up of two years were included. Postoperative outcome scores comprised the International Knee Documentation Society Score (IKDC), Lysholm score, Tegner activity score (TAS), and visual analog scale (VAS) for pain. Clinical meniscal healing failure was assessed according to Barrett’s criteria. Side-to-side difference in knee laxity was measured using KT-2000. Radiographic healing was assessed by 3-Tesla magnetic resonance imaging (MRI) and classified according to Henning’s criteria at final follow-up.ResultsForty patients with a mean age of 32.0 ± 11.5 years were available for follow-up after 51.8 ± 14.3 months. Revision surgery by means of arthroscopic partial meniscectomy was performed in four patients (10%) prior to the follow-up visit. The clinical healing rate was 83.3% at final follow-up. Mean IKDC score was 82.8 ± 13.8 and Lysholm score was 77.4 ± 24.8. Of all patients, 87.5% reached or exceeded the patient-acceptable symptomatic state (PASS) criteria for the IKDC score at final follow-up. The median TAS was 6 and VAS for pain was 0.46 ± 0.9. Side-to-side difference in knee laxity was higher in patients with concomitant ACL reconstruction (2.1 ± 2.7 mm) compared to isolated BHMTs (1.0 ± 2.0 mm). MR examination showed 69.4% healed, 25.0% partially healed, and 5.6% unhealed menisci.ConclusionPatients who underwent repair for acute traumatic BHMTs achieved good to excellent clinical outcome along with a high rate of meniscal healing at a minimum follow-up of two years. Clinical and radiological healing rates were similarly satisfactory and most patients exceeded the PASS criteria for the IKDC score. Patients were able to reach a high postoperative activity level.Level of evidenceCase Series; IV.

Function and return to sports after proximal humeral replacement in patients with primary bone sarcoma

BackgroundImproved patient and limb survival rates have led to an increased interest in the functional outcome and return to sports of patients undergoing megaprosthetic reconstruction in musculoskeletal oncology. This study evaluates the functional outcome and postoperatively performed level of sports in patients undergoing proximal humeral replacement (PHR) following resection of a primary bone sarcoma and identifies potential beneficial and limiting factors.Patients and methodsBetween 2007 and 2020, a total of 606 patients underwent resection of a primary bone sarcoma and reconstruction with a single-design modular implant. For 112 (18%) patients, the location of the tumour was the proximal humerus. Exclusion criteria were death (n = 65), patients living overseas (n = 8), and subsequent amputation (n = 1), leaving 38 patients for evaluation, of whom 32 were available for the study (13 women, median age 42 years). Clinical data regarding oncological and surgical treatment as well as subsequent complications were obtained from the patients’ electronic medical records. Functional outcome was determined using the Musculoskeletal Tumor Society Score (MSTS) and Toronto Extremity Salvage Score (TESS) as well as the Subjective Shoulder Value (SSV). Return to sports was assessed using the Tegner Activity Score (TS) and the modified Weighted Activity Score (WAS).ResultsAt the last follow-up after a median of 30 months (IQR 22–58), median MSTS was 18 (IQR 12–24), median TESS was 80% (IQR 69–87), median SSV was 35% (IQR 10–58), median TS was 5 (IQR 4–6) and median WAS was 5 (IQR 0–10). Preservation of the axillary nerve, a reverse shoulder reconstruction and a WAS of > 10 prior to surgery were associated with better functional outcome and return to sports activity scores.ConclusionFollowing PHR, good to excellent functional outcomes are possible, and patients regularly return to participate in sports activities—most commonly in low-impact types of sports, but some individuals are even able to participate in high-impact sports activities.Level of evidenceIV.

Promising functional outcomes following anterior cruciate ligament repair with suture augmentation.

There has been a renewed interest in the repair of the torn anterior cruciate ligament (ACL). Purpose of this study was to evaluate the functional outcome of arthroscopic ACL repair with additional suture augmentation (SA), hypothesizing that isolated ACL ruptures would yield superior patient-reported outcome measures (PROMs) compared to those with concomitant meniscal and/or ligamentous injuries. This is a retrospective analysis of 93 consecutive patients (67 female, median age 42years) who underwent arthroscopic ACL repair with SA between January 2017 and March 2019 for an acute traumatic ACL tear confirmed by magnetic resonance imaging (MRI). Patients with pre- or intraoperative mid-substance or distal ACL tears and/or poor tissue quality of the ACL remnant were not considered for ACL repair but were scheduled for an ACL reconstruction with a tendon autograft. In patients who underwent ACL repair with SA, the SA construct was proximally stabilized with a flip-button and distally with a suture anchor. Surgery was preferably performed on the day of injury and all surgeries were performed by the same surgeon. Postoperative rehabilitation included partial weight-bearing (20kg) for 6weeks and immobilization in a brace limited at 90-degrees of knee flexion for 4weeks. Patient-reported outcome measures (PROMs) were determined using International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm Score (LS), Tegner Activity Score (TS) and Forgotten Joint Score (FJS). Knee-laxity was assessed using the KT-1000 arthrometer (Med Metrics Corp. Inc., San Diego, USA). Nine patients underwent revision surgery for a traumatic re-tear (four patients) and chronic instability (five patients) and were excluded from further functional analysis. Functional results of 77 patients (54 female) with a median age of 44years (IQR 33-51) on the day of surgery were available for follow-up after a median time of 35months (IQR 33-44). Concomitant injuries were observed in 66 Patients (86%), meniscal injuries in 43 patients (55%) and ligamentous injuries in 50 patients (65%). Median interval from injury to surgery was 1day (IQR 0-1) with 81% (62/77) of patients being treated within 24h of injury. The median IKDC was 92 (IQR 86-99), the median LS was 95 (IQR 86-100), the median pre-traumatic TS was 7 (IQR 6-7), the median post-traumatic TS was 6 (IQR 5-7) with a non-significant median difference (TSDiff) of 0 (IQR 0-1). The median FJS was 95 (IQR 78-98). KT-1000 measurements were available in 34 of 77 patients with a median postoperative laxity compared to the uninjured side of 1mm (IQR 0-2). Interval from injury to surgery, patients' age, body mass index (BMI), knee laxity and concomitant ligamentous or meniscal injuries had no statistically significant impact on postoperative PROMs (n.s.). Following arthroscopic ACL repair with SA good-to-excellent functional results were observed. However, a failure rate of 10% cannot be neglected and warrants further attention. Concomitant injuries to the meniscus and/or collateral ligaments do not seem to be associated with inferior PROMs. Level IV.

Arthroscopic repair of degenerative medial meniscus tears in patients aged over 45 years resulted in favorable clinical outcomes and low clinical failure rates at a minimum 2-year follow-up.

This study aimed to investigate clinical and radiological results of arthroscopic repair for isolated medial degenerative meniscus tears (DMTs) in patients over 45years old at a minimum 2-year follow-up. From 2013 to 2017, patients aged over 45years with isolated medial DMT refractory to conservative management or with true mechanical symptoms who had undergone arthroscopic repair were retrospectively reviewed. Arthroscopic meniscus repair was performed using all-inside or all-inside and inside-out technique in combination with bone marrow venting procedure. Tear patterns were classified according to arthroscopic findings. Magnetic resonance imaging (MRI) and outcome evaluations, including Lysholm score, Tegner activity score, and International Knee Documentation Committee (IKDC) score, were evaluated preoperatively and at the final follow-up. International Cartilage Repair Society grades of the medial compartments and MRI signal at tear sites were assessed preoperatively and at the final follow-up. A grade 0 to 2 signal at the repair site suggested a healed meniscus, whereas a grade 3 signal suggested an unhealed meniscus. Clinical failure was determined according to Barrett criteria. Twenty-seven patients (mean age, 57.7 ± 7.4years) were enrolled. The mean follow-up was 52.0 ± 15.6months. Among tear patterns, 48% were complex tears, 30% were horizontal tears, and 22% were other patterns. The mean Lysholm score and IKDC score significantly improved from 53 ± 25 to 89 ± 15 (p < 0.001) and 34 ± 24 to 72 ± 15 (p < 0.001) at the final follow-up, respectively. The median Tegner activity score significantly improved from 1 (range 1-4) to 4 (range 2-7, p < 0.001). Three (11%) patients were considered clinical failures, and five patients (19%) had cartilage lesion progression. At the final follow-up, MRI showed grade 0 in one (4%) patient, grade 1 in nine (33%) patients, grade 2 in six (22%) patients, and grade 3 in eleven (41%) patients. Arthroscopic repair of isolated medial DMT refractory to conservative management or with true mechanical symptoms in patients aged over 45years had good to excellent clinical outcomes with low clinical failure rates, despite unhealed menisci being observed on MRI in 41% of patients at a mean 4.3-year follow-up. Arthroscopic repair could be a treatment option for these patients. IV.

Magnetic Resonance Imaging Assessment of Hamstring Graft Healing and Integration 1 and Minimum 2 Years after ACL Reconstruction

Background: An increase has been seen in the number of studies of anterior cruciate ligament reconstruction (ACLR) that use magnetic resonance imaging (MRI) as an outcome measure and proxy for healing and integration of the reconstruction graft. Despite this, the MRI appearance of a steady-state graft and how long it takes to achieve such an appearance have not yet been established. Purpose: To establish whether a hamstring tendon autograft for ACLR changes in appearance on MRI scans between 1 and 2 years and whether this change affects a patient’s ability to return to sports. Study Design: Case series; Level of evidence, 4. Methods: Patients with hamstring tendon autograft ACLR underwent MRI and clinical outcome measures at 1 year and at a final follow-up of at least 2 years. MRI graft signal was measured at multiple regions of interest using oblique reconstructions both parallel and perpendicular to the graft, with lower signal indicative of better healing and expressed as the signal intensity ratio (SIR). Changes in tunnel aperture areas were also measured. Clinical outcomes were side-to-side anterior laxity and patient-reported outcome measures (PROMs). Results: A total of 42 patients were included. At 1 year, the mean SIR for the graft was 2.7 ± 1.2. Graft SIR of the femoral aperture was significantly higher than that of the tibial aperture (3.4 ± 1.3 vs 2.6 ± 1.8, respectively; P = .022). Overall, no significant change was seen on MRI scans after 2 years; a proximal graft SIR of 1.9 provided a sensitivity of 96% to remain unchanged. However, in the 6 patients with the highest proximal graft SIR (>4) at 1 year, a significant reduction in signal was seen at final follow-up (P = .026), alongside an improvement in sporting level. A significant reduction in aperture area was also seen between 1 and 2 years (tibial, –6.3 mm2, P < .001; femoral, –13.3 mm2, P < .001), which was more marked in the group with proximal graft SIR >4 at 1 year and correlated with a reduction in graft signal. The patients had a high sporting level; the median Tegner activity score was 6 (range, 5-10), and a third of patients scored either 9 or 10. Overall, PROMs and knee laxity were not associated with MRI appearance. Conclusion: In the majority of patients, graft SIR on MRI did not change significantly after 1 year, and a proximal graft SIR <2 was a sensitive indicator for a stable graft signal, implying healing. Monitoring is proposed for patients who have a high signal at 1 year (proximal graft SIR >4), because a significant reduction in signal was seen in the second year, indicative of ongoing healing, alongside an improvement in sporting level. A reduction in tunnel aperture area correlated with a reduction in graft SIR, suggesting this could also be a useful measure of graft integration.

Factors influencing the outcome after surgical reconstruction of OTA type B and C tibial plateau fractures: how crucial is the restoration of articular congruity?

IntroductionOnly few and inconsistent data about the impact of articular congruity and tolerable residual intraarticular steps and gaps of the joint surface after tibial plateau fractures exist. Therefore, aim of this study was to investigate the correlation between OTA type B and C tibial plateau fracture outcomes and postoperative articular congruity using computed tomography (CT) data.Materials and methodsFifty-five patients with a mean age of 45.5 ± 12.5 years and treated for 27 type B and 28 C tibial plateau fractures with pre- and postsurgical CT data were included. Primary outcome measure was the correlation of postoperative intraarticular step and gap sizes, articular comminution area, the postoperative medial proximal tibial angle (MPTA), and the Lysholm and IKDC score. Receiver-operating characteristic (ROC) curves were used to determine threshold values for step and gap heights according to the following outcome scores: IKDC > 70; Lysholm > 80. Secondary outcome measures were the correlation of fracture severity, the number of complications and surgical revisions and the outcome scores, as well as the Tegner activity score before injury and at final follow-up.ResultsAfter a mean follow-up of 42.4 ± 18.9 months, the mean Lysholm score was 80.7 ± 13.3, and the mean IKDC score was 62.7 ± 17.6. The median Tegner activity score was 5 before the injury and 4 at final follow-up (p < 0.05). The intraarticular step height, gap size, comminution area and MPTA deviation were significantly negatively correlated with the IKDC and Lysholm scores. The cutoff values for step height were 2.6 and 2.9 mm. The gap size threshold was 6.6 mm. In total, an average of 0.5 ± 0.8 (range 0–3) complications occurred, and on average, 0.5 ± 1.1 (range 0–7) surgical revisions had to be performed. The number of complications and surgical revisions also had negative impacts on the outcome. Neither fracture severity nor BMI or patient’s age was significantly correlated with the IKDC or Lysholm score.ConclusionsTibial plateau fractures are severe injuries, which lead to a subsequent reduced level of patient activity. Precise reconstruction of the articular surface with regard to intraarticular step and gap size, residual comminution area and joint angle is decisive for the final outcome. Complications and surgical revisions also worsen it.Level of evidenceIII.

Non-Anatomical Arthroscopic All-Inside Repair of Medial Meniscus Posterior Root Tear to Posterior Cruciate Ligament for Patients with Normal Lower Limb Alignment.

ObjectiveTo describe a non‐anatomical arthroscopic all‐inside repair of medial meniscus posterior root tear (MMPRT) to posterior cruciate ligament (PCL) technique for patients with normal lower limb alignment and to evaluate the short‐term clinical and radiologic outcomes.MethodsMMPRT directly to PCL was repaired with all‐inside horizontal mattress suturing technique rather than by the transtibial pullout suture technique or anchor suturing repair technique in 20 Laparade Type II MMPRT patients with normal lower limb alignment during 2018–2019. The clinical and radiological outcomes were evaluated retrospectively for at least 2 years follow‐up. The VAS score, Lysholm score, Tegner activity score were evaluated preoperatively and at the final follow‐up. The status of the medial meniscus posterior root were assessed on magnetic resonance imaging (MRI) preoperatively and at the final follow‐up.ResultsTwenty patients (mean age 54.5 ± 19.5 years) were included in the present study. The mean follow‐up duration was 32.5 ± 5.8 months. The VAS score was significantly decreased from preoperative 6.5 ± 1.5 to 2.1 ± 1.4 at the final follow‐up (P < 0.01). The mean Lysholm score was significantly improved from 43.7 ± 10.9 preoperatively to 85.7 ± 10.8 (P < 0.01). The median Tegner activity score was improved from 1.0 (range 1–4) to 3.0 (range 2–4, P < 0.01). On MRI, a total of 12 cases (60%) had complete healing, while eight cases (40%) had partial healing.ConclusionNon‐anatomical arthroscopic all‐inside repair of MMPRT to PCL may yield beneficial clinical outcomes and a higher rate of clinical healing in Type II MMPRT patients with normal lower limb alignment. It is an easy and reliable alternative technique to the transtibial pullout suture or anchor suture repair technique.

Non-anatomic repair of medial meniscus posterior root tears to the posterior capsule provided favourable outcomes in middle-aged and older patients.

To describe a non-anatomic arthroscopic all-inside repair technique for middle-aged and older patients with medial meniscus posterior root tears (MMPRTs) and to evaluate the short- to mid-term clinical and radiologic results. The hypothesis was that this procedure would yield good clinical outcome results and structural healing in middle- and older-aged patients. This was a retrospective study evaluating patients who had undergone MMPRT repair by suturing the meniscal root directly to the capsule, rather than by the transtibial technique, between 2013 and 2016. This all-inside repair technique was performed for patients with type II MMPRTs who were over 40years old. Exclusion criteria included tibial osteotomy due to malalignment, concomitant multiple-ligament injuries and follow-up time less than 2years. The Lysholm score, Tegner activity score and International Knee Documentation Committee (IKDC) score were evaluated preoperatively and at the final follow-up. Medial meniscal extrusion, the International Cartilage Repair Society (ICRS) grades of the medial compartment, and the healing status of the medial meniscus root were assessed on magnetic resonance imaging preoperatively and at the final follow-up. Twenty-nine patients (mean age 61.7 ± 7.9) were included; the mean follow-up duration was 46.2 ± 7.9months. The mean Lysholm score significantly improved from 33.7 ± 20.9 preoperatively to 81.7 ± 19.9 at the final follow-up (p < 0.001), the median Tegner activity score improved from 1.0 (range 1-4) to 3.0 (range 2-4, p < 0.001), and the mean IKDC score improved from 20.1 ± 16.4 to 69.6 ± 16.2 (p < 0.001). On MRI, 9 (31%) cases had complete healing; 17 (59%) had partial healing; and 3 (10%) had failed healing (ICCs ≥ 0.92). Mean meniscal extrusion significantly increased from 2.3 ± 1.7mm preoperatively to 3.5 ± 1.5mm postoperatively (p < 0.001, ICCs ≥ 0.92). Non-anatomic arthroscopic all-inside repair of MMPRTs to the posterior capsule yielded good to excellent clinical results and a high rate of healing in the medial meniscus root on MRI in middle-aged and older patients at short- to mid-term follow-up, despite increased meniscal extrusion. This method is an alternative to the transtibial pullout repair technique for treating MMPRTs in middle- and older-aged patients. Level IV.

Clinical outcomes of primary anatomic all-inside Anterior Cruciate Ligament reconstruction using the TransLateral technique: A minimum one-year follow-up study

BackgroundAnatomic all-inside Anterior Cruciate Ligament (ACL) reconstruction using the TransLateral technique is relatively new. This technique utilises single tendon autograft and instruments permitting inside-to-out drilling to create retrograde sockets. Few studies have investigated clinical outcomes following this technique. We investigate clinical outcomes in patients who underwent primary anatomic all-inside ACL reconstruction using the TransLateral technique with a minimum one-year follow-up. MethodsInterrogation of our prospectively maintained database identified patients who underwent surgery from June 2013 to December 2017. Patients were followed up clinically and using patient-reported outcome measures (PROMS) including EQ-5D, KOOS, IKDC and Tegner scores from the National Ligament Registry. Paired two-tailed Student t-test was used to assess for clinical significance. ResultsOne hundred forty-one cases with a mean age of 30 years (range 16.0–60.2) and mean follow-up of 17.4 months (12.1–75.2) were included. Grafts included isolated quadrupled semitendinosus (n = 115) and both quadrupled semitendinosus and gracilis (n = 26). One hundred and two patients (72.3%) had complete peri-operative PROMS. Mean increases in EQ-5D VAS and IKDC scores were 18.9 and 29.2 points (p < 0.001). Significant peri-operative improvements were observed for all KOOS domains (p < 0.001). Median Tegner activity score increased by two levels (p < 0.001). Incidence of graft re-rupture was 5.7% (n = 8), all were following significant knee trauma and seven cases were mid-bundle femoral tunnel placements. ConclusionsAll-inside ACL reconstruction using the TransLateral technique demonstrates good clinical and functional outcomes with low complication and failure rate. Mid-bundle femoral tunnel placements have been abandoned in favour of placement deep within the anteromedial bundle footprint.

Midterm Outcomes following Acute Repair of Grade III Distal MCL Avulsions in Multiligamentous Knee Injuries.

There is limited evidence guiding management of medial collateral ligament (MCL) avulsions or functional disruptions distal to the medial joint line. This study aims to determine outcomes of a series of patients with grade III distal MCL injuries managed with acute surgical repair. Patients with grade III, distal MCL injuries, with or without multiligament involvement were identified. Demographic, clinical examination, and midterm patient-reported outcomes (PRO) data were collected. Clinical follow-up included physical examination and ligamentous stress testing at a minimum of 6 months. PROs included Lysholm's knee scoring scale, Tegner's activity score, and subjective International Knee Documentation Committee (IKDC) scores at minimum of 2 years follow-up. Of the 24 eligible patients, outcomes data were available for 20 (83%). Of the 20 included patients, 16 had a concomitant anterior cruciate ligament (ACL) injury, 3 had ACL and posterior cruciate ligament (PCL) injuries, and 1 had an isolated MCL injury. Mean time from injury to surgery was 5 weeks. At mean clinical follow-up of 20.3 months, all patients showed valgus stability and satisfactory range of motion (ROM). Anteroposterior stability was normal in all but one patient who demonstrated a 2+ posterior drawer but with firm end points. At a mean follow-up of 5.7 years for PROs, mean Lysholm's score was 91.5 (standard deviation [SD] = 12.2), median Tegner's activity score was 7 (range, 4-9), and mean subjective IKDC score was 88.8 (SD: 9.9). The surgical repair of grade III distal MCL injuries delivered satisfactory clinical and functional outcomes. Future comparative studies with larger patient samples are needed.

Revision ACL reconstruction using quadriceps or hamstring autografts leads to similar results after 4 years: good objective stability but low rate of return to pre-injury sport level.

Due to the increased importance of revision ACL reconstruction, this study aims to evaluate the outcome 4years after the surgery, compare two revision strategies and identify factors that influence the results. Seventy-nine patients who received a revision ACL reconstruction were retrospectively evaluated. All patients were assessed with an average follow-up of 4.4years (range 3.3-5.5years). The results of patients treated with a quadriceps autograft were compared with those treated with a hamstring autograft. Ninety-seven percent of patients had a KT-1000 side-to-side difference of ≤ 5mm (mean 1.7 ± 2.0mm). Pivot-shift test was absent or minor in 95%. In the SLTH-test, 70% of patients reached 90% of the contralateral side. The mean Lysholm score on follow-up was 83 ± 12 (56% excellent/good). The mean IKDC 2000 subjective evaluation score was 81 ± 14 (58% normal/almost normal). The median Tegner activity score was 6 (range 3-10), a median of 2 levels worse than before the first injury. Return to sport rate was 89% but only 34% of patients reached their pre-injury sport level. Most common cause for this reduction was fear of another injury. Three patients suffered a re-rupture. Patients with a hamstring autograft performed pivoting sports more often, but had worse pivot-shift results compared to those with a quadriceps autograft. No significant influence was seen for other parameters. Young, male patients with a high activity level and no chondral damage had the best results. Through revision ACL reconstruction, the goal of stabilizing the knee can be achieved in the majority of patients. However, a good function and a high activity level are significantly less common in these patients. The main reason for this is fear of a renewed ACL-injury. Both quadriceps and hamstring autografts were able to achieve a good outcome. Young, male, patients with a normal BMI, a high activity level and without cartilage damage seem to benefit the most from revision ACL surgery. The discrepancy between the good laxity restoration and the lower activity rate should therefore be a main point in clinical counseling when deciding for or against revision ACL-Reconstruction. III.

Medial patellofemoral ligament (MPFL) reconstruction using quadriceps tendon autograft provides good clinical, functional and patient-reported outcome measurements (PROM): a 2-year prospective study.

The medial patellofemoral ligament (MPFL) is the most important ligamentous stabilizer preventing lateral patella dislocation. Numerous surgical procedures for MPFL reconstruction have been described in the literature. The aim of this study was to investigate the clinical, functional and patient-reported (PROM) outcomes 2 years after minimally invasive MPFL reconstruction performed using an autologous strip of the quadriceps tendon. Thirty-six patients (38 knees) were included in the study. For MPFL reconstruction, a partial thickness autologous quadriceps tendon graft was used. All patients were evaluated clinically and with patient-reported outcome questionnaires including the Tegner, Lysholm and Kujala scores as well as a visual analogue scale (VAS) for pain preoperatively and at 6, 12 and 24 months postoperatively. A functional Back-in-Action (BIA) test battery, including a total of seven stability, agility and jumping tests, was performed on 19 (50%) patients at the final follow-up. One patient was lost to follow-up at 24 months. The mean age at the time of operation was 25.2 ± 6.1years. No redislocations occurred during the period of investigation. The mean Lysholm score improved significantly from 79.3 ± 16.1 preoperatively to 83.2 ± 14.4at 6months, 88.1 ± 11.3at 12months and to 90.0 ± 9.6at 24months follow-up. No change throughout the study period was observed for the median Tegner Activity Score (median 6). The mean Kujala score increased from a preoperative value of 82.0 ± 12.4, to 84.5 ± 8.4at 6months, and 88.2 ± 5.8at 12months up to 88.7 ± 4.5at 24months follow-up. A total of 77.8% of the performed functional BIA tests were equal to or above the norm for patients of the corresponding ages and activity levels. Minimally invasive MPFL reconstruction with a partial thickness strip of quadriceps tendon is a safe and effective treatment for patellofemoral instability. Good clinical, functional and subjective results were observed at the 2-year follow-up. Prospective cohort study, non-randomized, Level IV.

Double Bundle Posterior Cruciate Ligament Reconstruction in 100 Patients at a Mean 3 Years Follow up: Outcomes were Comparable to an Anterior Cruciate Ligament Reconstructions

Objectives:1) To report on the outcomes after double-bundle PCL reconstructions in isolated versus combined injuries and acute versus chronic PCL tears and 2) to compare the outcomes of isolated double-bundle PCL reconstruction (DB PCLR) to isolated ACL reconstruction (ACLR).Methods:All patients who underwent a primary arthroscopic assisted DB PCLR for grade-III isolated or combined PCL injuries between May 2010 and March 2015 were reviewed. Patient reported outcome scores (Lysholm, Tegner, Western Ontario and McMaster Universities Arthritis Index (WOMAC), 12 item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and patient satisfaction with outcome) and objective posterior stress radiographs were collected preoperatively and at a minimum of two years postoperatively. Cohort subanalyses comparing isolated versus combined, and acute versus chronic PCL reconstructions were also performed. Patients who underwent isolated ACLR over the same inclusion period were selected as a comparison group.Results:One hundred patients that underwent DB PCLR were included in this study. There were 31 isolated PCL injuries and 69 combined PCL injuries and the mean follow-up was 2.9 years (range 2-6 years). The median Tegner activity score improved from 2 to 5, Lysholm from 48 to 86, WOMAC from 35.5 to 5, and SF-12 PCS from 34 to 54.8 (all p values <0.001). The mean side-to-side difference (SSD) in posterior tibial translation on kneeling stress radiographs improved from 11.0 mm preoperatively to 1.6 mm postoperatively (p<0.001). There were no significant differences in postoperative functional scores between isolated PCL reconstructions and combined PCL reconstructions (all p values >0.229). The mean SSD in postoperative posterior tibial translation on stress radiographs was 1.2 ± 1.1 mm for isolated PCL tears and 1.7 ± 2.2 mm for combined PCL tears. The improvement in posterior tibial translation from preoperative to postoperative was significant for both the isolated and combined PCL injury groups (p<0.001). Only the Tegner score (p<0.001) and patient satisfaction (p=0.011) were significantly different postoperatively between acute and chronic reconstructions, both favoring acutely treated PCL injuries. The mean SSD in posterior tibial translation on stress radiographs improved from 11.6 ± 3.1 mm preoperatively to 1.9 ± 2.5 mm postoperatively (p<0.001) for acute PCL tears, and 10.3 ± 3.7 mm to 1.2 ± 1.0 mm (p<0.001) for chronic PCL tears. There were no significant differences in postoperative outcome scores between patients that underwent an isolated ACLR or isolated DB PCLR [all p values >0.064].Conclusion:Significantly improved functional and objective outcomes were observed after anatomic-based DB PCLR at a mean 3 years follow-up, regardless of concomitant ligamentous pathology or timing to surgery. Posterior tibial translation was restored to near normal after DB PCLR. Additionally, contrary to previous reports, similar results were achieved compared to a control isolated ACLR cohort.Table 1:Patient demographics and preoperative outcome scores demonstrating that the initial status of both cohorts was comparable. Data presented as counts, mean • SD or median [1st quartile, 3 rd quartile], unless otherwise noted. N/A=Not applicable; FET= Fisher’s exact tests; (χ2)= chi-squared tests; MWU=Mann-Whitney U-testsVariablePCL Reconstruction Cohort (n=100)ACL Reconstruction Cohort (n=141)P-Value Patients 100141N/A Age Mean 31.7 (range, 14-66)Mean 35.2 (range, 14-81)0.042* (MWU) Gender Male: 77Male: 63<0.001* (FET)Female: 23Female: 78 Follow-Up Interval (years) Mean 2.9 (range, 2-6)Mean 3.1 (range, 2-7)0.289 (MWU) Chronicity Acute: 52 Chronic: 48Acute: 93 Chronic: 480.033 (FET) Meniscus Tear Distribution None: 54 Medial Meniscus: 23 Lateral Meniscus: 16 Medial & Lateral Meniscus: 7None: 66 Medial Meniscus: 39 Lateral Meniscus: 21 Medial & Lateral: Meniscus: 150.590 (χ2) Outerbridge Grade IV Chondral lesions (Grade, Location) Full thickness lesions: 11NoneN/APreoperative Outcome ScoresPCL Reconstruction Cohort (n=100)ACL Reconstruction Cohort (n=141)P-Value Tegner Activity Scale 2 [1, 3]2 [1, 5]0.135 (MWU) Lysholm Score 49.6 ± 25.151.0 ± 23.20.691 (t-test) Western Ontario and McMaster Universities Arthritis Index Total 38.7 ± 27.935.2 ± 23.10.333 (t-test) Short Form-12 Physical Health Composite Score 37.6 ± 10.940.3 ± 9.70.015* (t-test)Fig 1.Difference in medians for functional outcome scales. Horizontal lines indicate 95% bootstrap confidence intervals.

Double-Bundle Posterior Cruciate Ligament Reconstruction in 100 Patients at a Mean 3 Years’ Follow-up: Outcomes Were Comparable to Anterior Cruciate Ligament Reconstructions

Background: Historically, outcomes of posterior cruciate ligament (PCL) reconstructions have been less predictable and reported to yield inferior results when compared with those for anterior cruciate ligament (ACL) reconstructions. Purpose: To report on the outcomes of double-bundle PCL reconstructions (DB PCLRs) in isolated versus combined injuries and acute versus chronic PCL reconstructions. To compare the outcomes of isolated DB PCLR with isolated ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent a primary endoscopic DB PCLR for complete PCL tears (grade III) between May 2010 and March 2015 were reviewed. Patient-reported outcome scores (Tegner, Lysholm, WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index], SF-12 [12-item Short Form Health Survey]) and objective posterior stress radiographs were collected preoperatively and at a minimum 2 years postoperatively. A cohort subanalysis was additionally performed between isolated and combined PCL reconstruction and acute versus chronic PCL reconstruction. Patients who underwent isolated ACL reconstructions over the same inclusion period (2010-2015) were selected as a comparison group. Results: One hundred patients who underwent DB PCLR were included in this study. There were 31 isolated PCL injuries, and 69 patients had concurrent combined PCL injuries requiring surgery. The mean follow-up for the PCL cohort was 2.9 years (range, 2-6 years). The median Tegner activity score improved from 2 to 5, Lysholm from 48 to 86, WOMAC from 35.5 to 5, and SF-12 Physical Component Summary from 34 to 54.8 (all P values <.001). The mean side-to-side difference in posterior tibial translation on kneeling stress radiographs improved from 11.0 ± 3.5 mm preoperatively to 1.6 ± 2.0 mm postoperatively (P < .001). There were no differences in postoperative functional scores between isolated PCL reconstructions and PCL-based multiligament reconstructions (all P values >.229). There was no significant difference in the reported outcome scores between acute and chronic reconstructions (all P values >.087) except for Tegner scores (P < .001) and patient satisfaction (P = .011) favoring acutely treated PCL injuries. There were no significant differences between patients who had an isolated DB PCLR and patients who underwent an isolated ACL reconstruction (n = 141) in postoperative outcome scores (all P values >.064). Conclusion: Significantly improved functional and objective outcomes were observed after anatomic DB PCLR at a mean 3 years’ follow-up, with low complication rates, regardless of concomitant ligamentous injury or timing to surgery. Additionally, contrary to previous reports, comparable subjective and functional clinical outcomes were achieved compared with an isolated ACL reconstruction control cohort.

Primary anatomical repair of proximal acl ruptures with suture anchors: 1 year follow-up

Aims and Objectives: ACL injuries are common. Going trough the literature, numerous studies show a healing potential for the repair of acl tears, histologically comparable to mcl healing. In this study, the postoperative follow-up after acl preservation was examined up to 1 year. Materials and Methods: We performed a prospective clinical follow-up in 13 sportive patients (case series, no comparison group). Inclusion criterias were a proximal avulsion tear of the acl, patient age under 50 years and surgery within 6 weeks after trauma. In an arthroscopic procedure, the quality of the acl tissue was examined and judged if suitable for a repair. Concomitant injuries were treated at the same time. Using a suture passer, a Bunnell stitch was created with a nonabsorbable suture through the anteromedial bundel as through the posterolateral bundel. The footprint of the acl was prepared with an awl for liberation of stem cells. The bundels were reattached to the origins of the footprint with two absorbable suture anchors. No drain was used. The postoperative protocoll was as follows: partial weight bearing for 4 weeks and wearing a protective brace with a limitation for extension and flexion of 0-0-90° for 4 weeks. At week 5, the brace was unlocked and range of motion and weight bearing were gradually increased at the level of comfort. Patients were examined at 6 weeks, 3 months, 6 months and 12 months after surgery. The stability was tested with the KT 1000, the subjective outcome with the ACL-RSI and the clinical outcome using the Tegner activity score, the Lysholm score, the KOOS score and the IKDC objective form. X-rays were done after 3 and 12 months, a MRI after 6 months. Between months 4 and 6, patients returned to their previous level of sport. Results: All 13 patients have been included in the 1 year follow-up. No rerupture was seen. There have been no major complications, as minor complications we observed 2 effusions of the knee 7 days after surgery which were treated with aspiration. The patients presented the following outcomes after 1 year: the mean anterior translation difference in the KT 1000 was 0,85 mm; the median Tegner activity score was 6 (range from 5 to 9); the median Lysholm score 95,9; the median KOOS was 94,5. The IKDC was A in 9 of 13 patients, B in 3 and C in 1 patient. The ACL-RSI in the 6 week follow-up was 64,14%, indicating a high level of subjective stability and confidence. This score increased gradually to the 1 year follow-up (94,5%). X-rays showed no pathologic bone signal or tunnel widening. MRI showed appropriately positioned and continous ligaments with scar tissue and an irregular signal due to suture material. Conclusion: In this study, the results 1 year after surgery with an anatomical repair of the acl are promising. Nearly all patients returned to their previous sports level, indicating healing potential for acl injuries. If patient selection is done carefully, this technique is a supplement in the treatment algorithm of acl injuries.

Anterior cruciate ligament reconstruction in patients over age sixty years

Background: We sought to determine outcomes of anterior cruciate ligament reconstruction (ACLR) in patients over 60 yr of age at the time of reconstruction. Methods: All patients over the age of 60 yr who underwent ACLR at our institution between 2005 and 2014 were identified. Patients were subsequently contacted and each completed a questionnaire that included a Knee injury and Osteoarthritis Outcome Score (KOOS), Marx and Tegner Activity Scores, patient satisfaction with the operation, and details of any subsequent surgical procedures on the index knee. Results: Ten patients met inclusion criteria, and all 10 were contacted at a mean of 4.4 yr after ACLR (range: 1.3-9.4 yr). The mean KOOS scores for each subscale were: pain 95.9, symptoms 90.4, activities of daily life 95.0, sport and recreation function 80.5, and knee-related quality of life 79.7. No patient underwent repeat surgery on the index knee. The median Tegner activity score was 3 (range, 2-6). Nine of the 10 patients reported that they were able to return to their preoperative activity level. All patients were subjectively satisfied with the results of their surgery and stated that they would do the operation again if given the choice. Conclusions: ACL reconstruction in patients over the age of 60 yr yields excellent patient-reported outcomes, high rates of return to preinjury activity level, and low revision risk when performed for symptomatic instability in the absence of significant osteoarthritis.

Double-bundle PCL Reconstruction: A Prospective Study of Two-year Patient Reported Outcomes with Stress Radiographs

Objectives:Reconstruction of grade-III posterior cruciate ligament (PCL) ruptures has historically been compromised by graft elongation and residual laxity. The purpose of this study was to report prospectively collected two-year outcomes and failure rates of double-bundle PCL reconstruction in a consecutive patient series with patient reported outcomes and quantitative stress radiographs. It was hypothesized that double bundle PCL reconstruction would result in improved subjective clinical outcomes, restoration of knee stability, and result in high patient satisfaction.Methods:A single surgeon consecutive series of patients that underwent double-bundle PCL reconstruction between June, 2010, and April, 2014, were followed prospectively. The technique is anatomically and biomechanically validated and utilizes two allografts (Achilles tendon for anterolateral bundle, tibialis anterior tendon for posteromedial bundle) in divergent femoral tunnels and a single tibial tunnel, each secured at the tibia at different knee angles to recreate the function of the two PCL bundles. Patient reported outcomes were collected preoperatively, and at a minimum two-year follow-up, including SF12, WOMAC, Tegner, Lysholm, and patient satisfaction. Posterior kneeling stress radiographs were obtained preoperatively and at the 6-month follow-up period. Failures were defined objectively as a difference of more than 3 mm in stress radiographs.Results:Sixty patients had greater than 2 year follow-up (mean 2.9 yrs). All subjective outcome measures improved except SF-12 mental component which was unchanged. The mean Lysholm score improved from 48 to 79. The mean WOMAC score improved from 39 to 11. The median SF-12 physical component score improved from 32 to 55. The median Tegner activity score improved from 2 to 5. The median patient satisfaction score was 8. Stress radiographs were available for 36 patients and improved from a preoperative side-to-side difference of 9.6 mm to 1.0 mm at 6 months follow-up. One failure occurred in a patient who had an 8 mm side-to-side difference at final follow-up and 18 mm pre-operatively.Conclusion:Double bundle PCL reconstruction results in improved patient reported outcomes and restoration of posterior knee stability. High patient satisfaction and low failure rates were found in this cohort of patients.

High prevalence of knee osteoarthritis at a minimum 10-year follow-up after knee dislocation surgery

Long-term outcomes and the prevalence of osteoarthritis after surgical treatment of knee dislocations are lacking in the literature. The purpose of this study was to investigate the prevalence of knee osteoarthritis and knee function at a minimum of 10 years after knee dislocation surgery. Sixty-five patients surgically treated for knee dislocations at a single level I trauma center between May 1996 and December 2004 were evaluated at a minimum of 10 years. Patients were evaluated with radiographs for knee osteoarthritis using the Kellgren-Lawrence (KL) grading system, Tegner activity score, Lysholm score, IKDC-2000, KOOS, subjective stability on physical examination, KT-1000 arthrometer, and single-leg hop tests. Osteoarthritis was defined as KL grades 2 or greater. The median follow-up time was 12.7 years (range 10.0-18.8years), and the median age was 46.9 years (range 26.8-76.1years). Radiographic osteoarthritis was present in 42% (23, 14, and 5% in KL grades II, III, and IV, respectively) of the patients in the operated knee compared to 6% in the uninjured knee. Knee function was generally improved with a median Tegner activity score of 4 (range 1-8), an average Lysholm score of 84 ± 17, and an average IKDC-2000 score of 73 ± 19. Twenty-seven patients (42%) developed OA 10 years after surgical treatment of knee dislocations. Patients reported improved knee function and minimal-to-moderate pain. Age at surgery was a predictor of development of OA, with more patients >30 years at the time of surgery developing OA. Meniscal and cartilage injuries at time of surgery were not associated with development of OA. Patients being treated for knee dislocation should be counselled about the increased long-term risk of post-traumatic OA. III.